The Neurologic ExamThe Neurologic Exam

Andy Jagoda, MDAndy Jagoda, MD

Department of Emergency MedicineDepartment of Emergency MedicineMount Sinai School of MedicineMount Sinai School of Medicine

New York, New YorkNew York, New York

Andy Jagoda, MD

OverviewOverview

• NeuroanatomyNeuroanatomy

• HistoryHistory

• PhysicalPhysical

• Clinical ScenariosClinical Scenarios

Andy Jagoda, MD

IntroductionIntroduction• Facilitates CommunicationFacilitates Communication

• Provides BaselineProvides Baseline

• Directs TestingDirects Testing

• Identifies Need For Life-Saving TherapiesIdentifies Need For Life-Saving Therapies

• Risk ManagementRisk Management

Andy Jagoda, MD

Risk Management: Case #1Risk Management: Case #1• A 46-year-old female with a long history of A 46-year-old female with a long history of

migraine headaches presented c/o a severe migraine headaches presented c/o a severe occipital HA that was different form her past occipital HA that was different form her past headaches in location and intensity. Neuro headaches in location and intensity. Neuro exam “WNL”. Patient was treated with exam “WNL”. Patient was treated with Compazine, 10 MG IV, with “Resolution of Compazine, 10 MG IV, with “Resolution of Headache” and discharged home to Headache” and discharged home to “Follow-Up With PMD”.“Follow-Up With PMD”.

• 18 hours later, patient was brought in by 18 hours later, patient was brought in by EMS comatoseEMS comatose

Andy Jagoda, MD

Risk Management: Case #2Risk Management: Case #2• A 64-year-old male presented with lower back pain A 64-year-old male presented with lower back pain

which had become progressively worse over the past 2 which had become progressively worse over the past 2 weeks. The pain was primarily in the lower back without weeks. The pain was primarily in the lower back without radiation, with nonspecific numbness in the legs. PMH: radiation, with nonspecific numbness in the legs. PMH: presently being treated for prostatitis. Exam: “Mild presently being treated for prostatitis. Exam: “Mild Paralumbar Tenderness”, “SLR -”, “Motor / Sensory Paralumbar Tenderness”, “SLR -”, “Motor / Sensory Intact”, Knee DTR +2. patient was prescribed Motrin and Intact”, Knee DTR +2. patient was prescribed Motrin and told to follow-up with his PMD.told to follow-up with his PMD.

• Patient developed irreversible renal damage.Patient developed irreversible renal damage.

Andy Jagoda, MD

NeuroanatomyNeuroanatomy• Central versus peripheralCentral versus peripheral– symmetrical vs asymmetricalsymmetrical vs asymmetrical

• If central, what is the level:If central, what is the level:– Cerebrum Cerebrum – Brain StemBrain Stem– Spinal cordSpinal cord

• If peripheral, is itIf peripheral, is it– NerveNerve– MuscleMuscle– NMJNMJ

Andy Jagoda, MD

NeuroanatomyNeuroanatomy

Andy Jagoda, MD

Central lesionsCentral lesions• Lesions in the cerebral cortex result in contralateral Lesions in the cerebral cortex result in contralateral

deficits of the face and body deficits of the face and body • Lesions at the midbrain result in contralateral Lesions at the midbrain result in contralateral

hemiplegia and ipsilateral peripheral paralysis of hemiplegia and ipsilateral peripheral paralysis of III and IVIII and IV

• Lesions at the pons result in contralateral Lesions at the pons result in contralateral hemiplegia and ipsilateral deficits of V, VI, VII, VIIIhemiplegia and ipsilateral deficits of V, VI, VII, VIII

• Lesions at the medulla result in contraleral Lesions at the medulla result in contraleral hemiplegia and ipsilateral deficits of IX, X, XI, XIII hemiplegia and ipsilateral deficits of IX, X, XI, XIII

Andy Jagoda, MD

Anatomy of the Spinal CordAnatomy of the Spinal Cord• Corticospinal Tracts: motor from Corticospinal Tracts: motor from

cerebral cortex: cross in the lower cerebral cortex: cross in the lower medulla medulla

• Spinothalamic Tracts: pain and Spinothalamic Tracts: pain and temperature: cross 1 or 2 levels above temperature: cross 1 or 2 levels above entry entry

• Posterior Column: proprioception and Posterior Column: proprioception and vibrationvibration

Andy Jagoda, MD

Spinal Cord : Vascular SupplySpinal Cord : Vascular Supply• Single Anterior Single Anterior • Paired posterior from vertebral arteries (Except in Paired posterior from vertebral arteries (Except in

cervical cord)cervical cord)• Radicular Arteries from aorta: Radicular Arteries from aorta: – Varying degrees of contributionVarying degrees of contribution– Great radicular artery of Adamkiewicz T-10 to L-2 (Major Great radicular artery of Adamkiewicz T-10 to L-2 (Major

source of blood flow to 50% of anterior cord in 50% of source of blood flow to 50% of anterior cord in 50% of patients)patients)

• Anterior perfuses anterior and central cordAnterior perfuses anterior and central cord

Andy Jagoda, MD

UMN vs LMN UMN vs LMN

• UMN increased DTR (after SS) UMN increased DTR (after SS) LMN decreased DTR LMN decreased DTR

• UMN muscle tone increased UMN muscle tone increased LMN tone decreased, atrophyLMN tone decreased, atrophy

• UMN no fasciculations UMN no fasciculations LMN fasciculations LMN fasciculations

Andy Jagoda, MD

UMN vs LMN WeaknessUMN vs LMN Weakness• Mylopathy = Spinal Cord Process = UMN Mylopathy = Spinal Cord Process = UMN

findings (spasticity, weakness, atrophy, findings (spasticity, weakness, atrophy, sensory findings, bowel and bladder sensory findings, bowel and bladder complaints)complaints)

• Radiculopathy = Nerve Root Process = LMN Radiculopathy = Nerve Root Process = LMN findings (Paresthesias, Fasciculations, findings (Paresthesias, Fasciculations, Weakness, decreased DTR)Weakness, decreased DTR)

• Patient may have a radiculopathy with Patient may have a radiculopathy with mylopathy below the lesionmylopathy below the lesion

Andy Jagoda, MD

The Neuro Exam: HistoryThe Neuro Exam: History

• Neuro complaints may be primary or Neuro complaints may be primary or secondary to other system diseasesecondary to other system disease– Infection Infection –Overdose Overdose –Metabolic DisorderMetabolic Disorder

Andy Jagoda, MD

The Neuro Exam: HistoryThe Neuro Exam: History

• History often provides the key since History often provides the key since the neuro exam may be normalthe neuro exam may be normal–Subarachnoid HemorrhageSubarachnoid Hemorrhage–Carbon Monoxide PoisoningCarbon Monoxide Poisoning–Subdural HematomaSubdural Hematoma–Nonconvulsive SeizuresNonconvulsive Seizures

Andy Jagoda, MD

The Neuro Exam: HistoryThe Neuro Exam: History

• Time of OnsetTime of Onset

• Type of OnsetType of Onset

• ProgressionProgression

• TraumaTrauma

• Associated SymptomsAssociated Symptoms

Andy Jagoda, MD

The Neuro Exam: HistoryThe Neuro Exam: History

• Factors that make it better/worseFactors that make it better/worse

• Past Symptoms / EventsPast Symptoms / Events

• Past Medical HistoryPast Medical History

• Occupational / Environ ExposuresOccupational / Environ Exposures

Andy Jagoda, MD

The Neuro Exam: PhysicalThe Neuro Exam: Physical• Vital SignsVital Signs• Head: Evidence of TraumaHead: Evidence of Trauma• Neck: Bruits, RigidityNeck: Bruits, Rigidity• Heart: MurmursHeart: Murmurs• Abdomen: Masses / DistentionAbdomen: Masses / Distention• Skin / Scalp: Lesions / TendernessSkin / Scalp: Lesions / Tenderness

Andy Jagoda, MD

The Neuro Exam: Physical The Neuro Exam: Physical • Mental StatusMental Status• Cranial NervesCranial Nerves• MotorMotor• SensorySensory• CoordinationCoordination• ReflexesReflexes

Andy Jagoda, MD

The Neuro Exam: Initial ApproachThe Neuro Exam: Initial Approach

• PosturePosture–DecorticateDecorticate–DecerebrateDecerebrate– Facial or body asymmetryFacial or body asymmetry• Hemiparesis results in external rotation of Hemiparesis results in external rotation of

the foot of the affected side the foot of the affected side

Andy Jagoda, MD

Mental Status ExamMental Status Exam

• AVPUAVPU

• GCSGCS

• Orientation Orientation –Speech (dysarthria vs aphasia)Speech (dysarthria vs aphasia)–ComprehensionComprehension

Andy Jagoda, MD

Mental Status ExamMental Status Exam• Confusion assessment method (CAM)Confusion assessment method (CAM)– Acute onset / fluctuating course Acute onset / fluctuating course – Inattention Inattention – Disorganized thinking Disorganized thinking – Altered level of consciousnessAltered level of consciousness

• Mini-mental status examMini-mental status exam– Score affected by education and age Score affected by education and age – <20 = cognitive impairment<20 = cognitive impairment

Andy Jagoda, MD

Acute Altered Mental StatusAcute Altered Mental Status• Intracranial lesionIntracranial lesion• Metabolic disorderMetabolic disorder• ToxinToxin• InfectionInfection• Ictal stateIctal state• Postictal state Postictal state • PsychogenicPsychogenic

Andy Jagoda, MD

Cranial Nerve ExamCranial Nerve Exam

• Focus exam on II - VIIIFocus exam on II - VIII

• Symmetrical vs asymmetrical Symmetrical vs asymmetrical

Andy Jagoda, MD

Evaluation of II, III, IV, VIEvaluation of II, III, IV, VI• Visual acuityVisual acuity• Visual fieldsVisual fields• Examine the cornea, pupil, fundiExamine the cornea, pupil, fundi• Check afferent functionCheck afferent function• Extraocular movements Extraocular movements

– Accentuated when looking in the direction of the Accentuated when looking in the direction of the paralyzed muscle paralyzed muscle

– Differentiation can be facilitated by placing a colored Differentiation can be facilitated by placing a colored glass over one eyeglass over one eye

Andy Jagoda, MD

Cranial Nerve IICranial Nerve II

• Visual acuityVisual acuity

• Visual fields Visual fields

• FundoscopyFundoscopy

• Swinging flashlight testSwinging flashlight test

Andy Jagoda, MD

III NerveIII Nerve

• Emerges from brainstem next to Emerges from brainstem next to posterior cerebral arteryposterior cerebral artery

• May be compressed by herniationMay be compressed by herniation

• Runs in the lateral wall of the Runs in the lateral wall of the cavernous sinuscavernous sinus

Andy Jagoda, MD

LR MR MR LR

IO IO SRSR

IR SO SO IR

III Cranial NerveIII Cranial Nerve

• ParasympatheticsParasympathetics

• Levator PalpebraeLevator Palpebrae

• Inferior Obliques, Medial, Inferior, Inferior Obliques, Medial, Inferior, and Superior Rectus Musclesand Superior Rectus Muscles

Andy Jagoda, MD

LR MR MR LR

IO IO SRSR

IR SO SO IR

III Cranial Nerve ParalysisIII Cranial Nerve Paralysis• PtosisPtosis

• Dilated PupilDilated Pupil

• Paralyzed eye is deviated out and down; Paralyzed eye is deviated out and down; SO and LR control eyeSO and LR control eye

Andy Jagoda, MD

III Cranial Nerve LesionsIII Cranial Nerve Lesions• Progressive lesions after passage Progressive lesions after passage

through the dura usually usually causes through the dura usually usually causes a ptosis and pupil dilatation firsta ptosis and pupil dilatation first

• Lesions in the nucleus cause motor Lesions in the nucleus cause motor deficits firstdeficits first

• Intact pupil indicates a peripheral Intact pupil indicates a peripheral ischemic lesionischemic lesion

Andy Jagoda, MD

LR MR MR LR

IO IO SRSR

IR SO SO IR

IV Cranial NerveIV Cranial Nerve• Superior obliqueSuperior oblique

• Causes eye to turn in and downCauses eye to turn in and down

• When paralyzed, eye can not turn When paralyzed, eye can not turn down when it is rotated indown when it is rotated in

Andy Jagoda, MD

LR MR MR LR

IO IO SRSR

IR SO SO IR

VI Cranial NerveVI Cranial Nerve• Lateral rectusLateral rectus

• Long course; goes through the CS, Long course; goes through the CS, not within the wallnot within the wall

• Paralysis impairs abductionParalysis impairs abduction

Andy Jagoda, MD

Conjugate GazeConjugate Gaze• Controlled by supranuclear connectionsControlled by supranuclear connections• Medial longitudinal fasciculus is Medial longitudinal fasciculus is

responsible for coordinating the responsible for coordinating the oculomotor nerves; lesions result in oculomotor nerves; lesions result in impairment of LR and MR moving in impairment of LR and MR moving in sync, ie, contralateral eye does not pass sync, ie, contralateral eye does not pass the midlinethe midline

• Multiple sclerosisMultiple sclerosis

Andy Jagoda, MD

Causes of III, VI, VI CN ParalysisCauses of III, VI, VI CN Paralysis• Isolated cases usually due to vascular causes: Isolated cases usually due to vascular causes:

HTN, DM, AtherosclerosisHTN, DM, Atherosclerosis• TumorsTumors• Increased intracranial pressureIncreased intracranial pressure• Colloid cyst of the III ventricleColloid cyst of the III ventricle• Wernicke-Korsakoff syndromeWernicke-Korsakoff syndrome• Myasthenia, BotulismMyasthenia, Botulism• Toxic drug reactionsToxic drug reactions

Andy Jagoda, MD

Cranial Nerve VCranial Nerve V• Sensory: corneal reflexes Sensory: corneal reflexes • Motor: jaw strength and muscle Motor: jaw strength and muscle

bulkbulk• Corneal reflex may be abnormal in Corneal reflex may be abnormal in

cerebellopontine angle lesions: test cerebellopontine angle lesions: test in patients with hearing deficits or in patients with hearing deficits or vertigovertigo

Andy Jagoda, MD

Cranial Nerve VIICranial Nerve VII• MotorMotor– SmileSmile– Bury eyelashesBury eyelashes– Nasolabial foldNasolabial fold– Forehead has bihemispheric innervation Forehead has bihemispheric innervation

centrallycentrally

• Taste anterior 2/3 Taste anterior 2/3

Andy Jagoda, MD

Cranial Nerves VIII - XIICranial Nerves VIII - XII

• VIII - vestibular function / hearingVIII - vestibular function / hearing

• IX - taste / sensation posterior IX - taste / sensation posterior pharynxpharynx

• X - SCM; chin to the opposite side X - SCM; chin to the opposite side

• XII - tongueXII - tongue

Andy Jagoda, MD

Motor ExamMotor Exam• StrengthStrength– Primary concern: can patient breathePrimary concern: can patient breathe– Key test: drift of extremityKey test: drift of extremity

• ToneTone– Hypertonia: subacute or chronic corticospinal Hypertonia: subacute or chronic corticospinal

lesion lesion – Hypotonia: LMN lesion or acute UMNHypotonia: LMN lesion or acute UMN– Rigidity: basal ganglia diseaseRigidity: basal ganglia disease

Andy Jagoda, MD

Motor ExamMotor Exam

• BulkBulk– Wasting correlates with LMNWasting correlates with LMN

• FasciculationFasciculation– Anterior horn cell lesionAnterior horn cell lesion

• TendernessTenderness– Metabolic / inflammatory muscle diseaseMetabolic / inflammatory muscle disease

Andy Jagoda, MD

Motor ExamMotor Exam• 00 = no movement = no movement• 11 = flicker but no movement = flicker but no movement• 22 = movement but can not resist gravity = movement but can not resist gravity• 33 = movement against gravity but can not = movement against gravity but can not

resist examinerresist examiner• 44 = resists examiner but weak = resists examiner but weak• 55 = normal = normal

Andy Jagoda, MD

Sensory ExamSensory Exam

• Pain / TempPain / Temp - cross at entrance, - cross at entrance, ascend in spinal thalamic tractascend in spinal thalamic tract

• Light touchLight touch - ascend in posterior - ascend in posterior column, cross in the brain stemcolumn, cross in the brain stem

• VibrationVibration - posterior column, cross - posterior column, cross in the brain stemin the brain stem

Andy Jagoda, MD

Sensory Exam Sensory Exam

• Dermatomal deficit accompanied Dermatomal deficit accompanied with pain suggests peripheral lesionwith pain suggests peripheral lesion

• Central deficits are not dermatomal Central deficits are not dermatomal and usually result in loss of and usually result in loss of sensation not painsensation not pain

• Thalamic pain syndromeThalamic pain syndrome

Andy Jagoda, MD

Sensory ExamSensory Exam• DistributionDistribution– Right vs left vs bilateralRight vs left vs bilateral– DermatomalDermatomal– Distal versus proximalDistal versus proximal

• Stocking gloveStocking glove• Cape likeCape like

• Pinprick versus light touchPinprick versus light touch

Andy Jagoda, MD

Sensory ExamSensory Exam

• Double simultaneous testingDouble simultaneous testing– Establish sharp / dullEstablish sharp / dull– Check cheek, dorsum of hands, dorsum of Check cheek, dorsum of hands, dorsum of

feetfeet– Test both sides simultaneously with pinTest both sides simultaneously with pin• lateralizes pain, significant sensory deficit lateralizes pain, significant sensory deficit • initially no lateralization but on repeat 15 sec initially no lateralization but on repeat 15 sec

later, lateralization suggests subtle deficit later, lateralization suggests subtle deficit

Andy Jagoda, MD

CoordinationCoordination• Requires integration of cerebellar, motor, and Requires integration of cerebellar, motor, and

sensory functionssensory functions• Balance requires (2 of 3)Balance requires (2 of 3)

– visionvision– vestibular sensevestibular sense– proprioceptionproprioception

• Falling with eyes open or closed = cerebellarFalling with eyes open or closed = cerebellar• Falling only with eyes closed = posterior column or Falling only with eyes closed = posterior column or

vestibularvestibular

Andy Jagoda, MD

ReflexesReflexes• Symmetry / upper vs lowerSymmetry / upper vs lower– 0 = absent0 = absent– 1 = hyporeflexia1 = hyporeflexia– 2 = normal2 = normal– 3 = hyperreflexia3 = hyperreflexia– 4 = clonus (4 = clonus (usuallyusually indicates organic disease) indicates organic disease)

• Superficial reflexes (corneal, pharyngeal, pharyngeal, Superficial reflexes (corneal, pharyngeal, pharyngeal, abdominal, anal, cremasteric, bulbocavernosus)abdominal, anal, cremasteric, bulbocavernosus)

• Pathologic reflexes: babinskiPathologic reflexes: babinski

Andy Jagoda, MD

Hysteria Hysteria (conversion vs malingering)(conversion vs malingering)

• Blindness: opticokinetic testBlindness: opticokinetic test• Hand drop on face test for coma or UE weaknessHand drop on face test for coma or UE weakness• Hemianesthesia: if real, patient cannot perform finger-Hemianesthesia: if real, patient cannot perform finger-

to nose with eyes closed; vibration remains intact (if to nose with eyes closed; vibration remains intact (if bony skeleton intact)bony skeleton intact)

• Weakness: elbow extension or flexor test; wrist Weakness: elbow extension or flexor test; wrist extensor testextensor test

• Unilateral LE weakness: thigh abduction test, hoover Unilateral LE weakness: thigh abduction test, hoover test test

Andy Jagoda, MD

Pitfalls In The Neurologic Exam Pitfalls In The Neurologic Exam • Not getting a complete history utilizing family Not getting a complete history utilizing family

or observers or observers • Not performing a systematic examNot performing a systematic exam• Jumping to conclusions before gathering all Jumping to conclusions before gathering all

the datathe data• Misinterpreting old lesions for new Misinterpreting old lesions for new • Misinterpreting limitations from pain as Misinterpreting limitations from pain as

neurologic deficits neurologic deficits

Andy Jagoda, MD

PearlsPearls

• Lesions of the cerebral cortex result in Lesions of the cerebral cortex result in sensory and motor defects confined to the sensory and motor defects confined to the contralateral side of the bodycontralateral side of the body

• Brain stem and spinal cord lesions result Brain stem and spinal cord lesions result in ipsilateral as well as contralateral in ipsilateral as well as contralateral defects due to varying patterns of defects due to varying patterns of crossovercrossover

Andy Jagoda, MD

PearlsPearls• Unilateral pain syndromes without motor Unilateral pain syndromes without motor

deficits suggest possible thalamic deficits suggest possible thalamic pathologypathology

• A careful exam of CN II, III, IV, and IV is A careful exam of CN II, III, IV, and IV is indicated in patients with headache or indicated in patients with headache or suspected processes that cause increased suspected processes that cause increased ICPICP

• Testing for pronator drift is the best screen Testing for pronator drift is the best screen for muscle weakness of central originfor muscle weakness of central origin

Andy Jagoda, MD

The Neurologic Exam The Neurologic Exam

Case ScenariosCase Scenarios

Andy Jagoda, MD

Case Scenario #1Case Scenario #1 A 46-year-old female with a long history of A 46-year-old female with a long history of

migraine headaches presented c/o a migraine headaches presented c/o a severe occipital HA that was different from severe occipital HA that was different from her past headaches in location and her past headaches in location and intensity. If an aneurysm is suspected to intensity. If an aneurysm is suspected to be causing the patient’s symptoms, which be causing the patient’s symptoms, which cranial nerve should your exam focus on?cranial nerve should your exam focus on?

A. III B. VI C. VII D. IVA. III B. VI C. VII D. IV

Andy Jagoda, MD

III NERVEIII NERVE• Emerges from brainstem next to posterior cerebral arteryEmerges from brainstem next to posterior cerebral artery• Runs in the lateral wall of the cavernous sinusRuns in the lateral wall of the cavernous sinus• May be compressed:May be compressed:– HerniationHerniation– AneurysmAneurysm

• Posterior communicating arteryPosterior communicating artery• ICA in the cavernous sinus (IV, V and VI nerves ICA in the cavernous sinus (IV, V and VI nerves

also involved)also involved)

Andy Jagoda, MD

Case Scenario #2Case Scenario #2 A 64-year-old male presented C/0 low back A 64-year-old male presented C/0 low back

pain which has become progressively pain which has become progressively worse over the past 2 weeks. The pain worse over the past 2 weeks. The pain was primarily in the low back without was primarily in the low back without radiation; C/O nonspecific numbness in radiation; C/O nonspecific numbness in the legs. Which nerve root is responsible the legs. Which nerve root is responsible for plantar flexion and the ankle jerk? for plantar flexion and the ankle jerk?

A. L3 B. L4 C. L5 D. S1 E. S2A. L3 B. L4 C. L5 D. S1 E. S2

Andy Jagoda, MD

Lower Extremity InnervationLower Extremity Innervation

• L 3 / L 4 = Patellar reflexL 3 / L 4 = Patellar reflex

• L 5 = Big toe extensionL 5 = Big toe extension

• S 1 = Achilles reflexS 1 = Achilles reflex

Andy Jagoda, MD

Case Scenario #3Case Scenario #3A 30-year-old female is in an MVA hitting her head on A 30-year-old female is in an MVA hitting her head on the dash. The next day she developed a sudden onset the dash. The next day she developed a sudden onset severe right frontal HA, that persisted. One day later severe right frontal HA, that persisted. One day later she developed left sided arm weakness that lasted 2 she developed left sided arm weakness that lasted 2 hours. In the ED she had an OD ptosis and OD miosis. hours. In the ED she had an OD ptosis and OD miosis. Her motor / sensory exam was “WNL”. What is your Her motor / sensory exam was “WNL”. What is your initial impression? initial impression? A.A. Hysteria Hysteria B.B. Subarachnoid bleed Subarachnoid bleed C.C. Epidural hematoma Epidural hematoma D.D. Carotid artery dissection Carotid artery dissection E.E. Entrapment syndrome Entrapment syndrome

Andy Jagoda, MD

Pupil ConstrictionPupil Constriction• Disruption of the sympatheticsDisruption of the sympathetics– Horner’sHorner’s– Carotid artery dissectionCarotid artery dissection– Pontine hemorrhagePontine hemorrhage

• ToxinsToxins– NarcoticsNarcotics– CholinergicsCholinergics

Andy Jagoda, MD

Case Scenario #4Case Scenario #4A 50-year-old female c/o a diffuse headache for two A 50-year-old female c/o a diffuse headache for two months that is constant. There is no past HA history. months that is constant. There is no past HA history. She claims that intermittently her vision seems blurred She claims that intermittently her vision seems blurred but otherwise denies symptoms. On exam: VSS; VA: but otherwise denies symptoms. On exam: VSS; VA: 20/40. CN: diplopia on far lateral gaze bilaterally. 20/40. CN: diplopia on far lateral gaze bilaterally. Which of the following is the most likely diagnosis. Which of the following is the most likely diagnosis. A.A. Occipital Lobe Stroke Occipital Lobe Stroke B.B. Pituitary Adenoma Pituitary AdenomaC.C. Multiple Sclerosis Multiple Sclerosis D.D. Myasthenia Gravis Myasthenia Gravis

E.E. Intracranial Hypertension Intracranial Hypertension

Andy Jagoda, MD

Idiopathic Intracranial Hypertension Idiopathic Intracranial Hypertension (Benign Intracranial (Benign Intracranial

Hypertension, Pseudotumor Cerebri)Hypertension, Pseudotumor Cerebri)

• Syndrome Defined By Signs And Symptoms Of Syndrome Defined By Signs And Symptoms Of High ICP Without Apparent Intracranial MassHigh ICP Without Apparent Intracranial Mass

• 50% Have An Identifiable Underlying Etiology50% Have An Identifiable Underlying Etiology

• Altered Absorption Of Csf At The Arachnoid VillusAltered Absorption Of Csf At The Arachnoid Villus

• Alteration Due To Either:Alteration Due To Either:– Elevated Pressure Within The Sagittal SinusElevated Pressure Within The Sagittal Sinus– Increased Resistance To Drainage Of Csf Within The Increased Resistance To Drainage Of Csf Within The

VillusVillus

Andy Jagoda, MD

Physical FindingsPhysical Findings• PapilledemaPapilledema• Visual disturbance Visual disturbance 50 - 80%50 - 80%– Blindness in Blindness in 10%10%– Decreased visual acuityDecreased visual acuity 30%30%– Transient visual obscurationTransient visual obscuration 68%68%– Enlarged blind spotEnlarged blind spot– ScotomasScotomas– VI nerve palsy (false localizing)VI nerve palsy (false localizing) 38%38%

Andy Jagoda, MD

Case Scenario #5Case Scenario #5A 20-year-old college student flips his car, hitting head A 20-year-old college student flips his car, hitting head on the dash. He arrives in the ED in full spinal on the dash. He arrives in the ED in full spinal immobilization. On exam he has 2/5 strength in his immobilization. On exam he has 2/5 strength in his wrists, 3/5 strength in his deltoids, 5/5 strength in his wrists, 3/5 strength in his deltoids, 5/5 strength in his LE. He complains of numbness in his arms but is able LE. He complains of numbness in his arms but is able to distinguish sharp from dull. DTRs intact. What is to distinguish sharp from dull. DTRs intact. What is your leading diagnosis?your leading diagnosis?A.A. Central Cord Syndrome Central Cord Syndrome B.B. Anterior Cord Syndrome Anterior Cord SyndromeC.C. Spinal Epidural Hemorrhage Spinal Epidural Hemorrhage D.D. Subdural Hemorrhage Subdural HemorrhageE.E. Brown - Sequard Syndrome Brown - Sequard Syndrome

Andy Jagoda, MD

Central Cord SyndromeCentral Cord Syndrome

• Hyperextension injuries, tumor, Hyperextension injuries, tumor, syringomyeliasyringomyelia

• MUDMUD

• Paresis or plegia of arms > legsParesis or plegia of arms > legs

• Posterior column sparedPosterior column spared

Andy Jagoda, MD

Central Cord SyndromeCentral Cord Syndrome

• Sensation ue>le; sacral sparingSensation ue>le; sacral sparing

• Perforating branches of anterior Perforating branches of anterior spinal artery at greatest risk for spinal artery at greatest risk for vascular insultvascular insult

• Good prognosisGood prognosis

Andy Jagoda, MD

Case Scenario #6Case Scenario #6A 23-year-old female presents complaining of feeling A 23-year-old female presents complaining of feeling generally weak with the sensation that she is dragging generally weak with the sensation that she is dragging her feet when she walks. On exam her sensation is her feet when she walks. On exam her sensation is intact; motor strength is 5/5 in all major muscle groups; intact; motor strength is 5/5 in all major muscle groups; deep tendon reflexes are 2/2 in the UE, 2/2 at the knees, deep tendon reflexes are 2/2 in the UE, 2/2 at the knees, and and 0/2 at the ankles. What is your major concern?and and 0/2 at the ankles. What is your major concern?A.A. Spinal Stenosis Spinal Stenosis B.B. Conus Medularis Conus Medularis C.C. Guillian Barre Guillian Barre D.D. Polymyalgia Rheumatica Polymyalgia Rheumatica E.E. Myasthenia Gravis Myasthenia Gravis

Andy Jagoda, MD

Guillain-BarreGuillain-Barre• Acute polyneuropathyAcute polyneuropathy• Symmetric ascending weaknessSymmetric ascending weakness• Arrflexia (LMN)Arrflexia (LMN)• No meningeal signs, fever, signs of No meningeal signs, fever, signs of

systemic illnesssystemic illness• CSF: increased protein without CSF: increased protein without

pleocytosispleocytosis

Andy Jagoda, MD

Case Scenario #7Case Scenario #7A 30-year-old male with AIDS complains of diffuse A 30-year-old male with AIDS complains of diffuse weakness that is progressive in the LE associated with weakness that is progressive in the LE associated with paresthesias; there is no back pain. On exam he has 4/5 paresthesias; there is no back pain. On exam he has 4/5 upper extremity strength, 2/5 lower extremity strength; upper extremity strength, 2/5 lower extremity strength; DTRs are 2/2 in the UE and 4/2 in the LE. His plantar DTRs are 2/2 in the UE and 4/2 in the LE. His plantar reflexes are upgoing upgoing bilaterally. reflexes are upgoing upgoing bilaterally. Which of the following is the most likely diagnosis?Which of the following is the most likely diagnosis?A.A. Myelopathy Myelopathy B.B. Neuropathy Neuropathy C.C. Myopathy MyopathyD.D. Neuromuscular Junction Disease Neuromuscular Junction Disease E.E. Radiculopathy Radiculopathy

Andy Jagoda, MD

HTLV-1 Associated MyelopathyHTLV-1 Associated Myelopathy• Progressive lower extremity weakness Progressive lower extremity weakness

(arms more than legs)(arms more than legs)• SpasticitySpasticity• Paresthesias are common; sensory deficits Paresthesias are common; sensory deficits

are rareare rare• Symmetric upper motor neuron paraparesisSymmetric upper motor neuron paraparesis• Sphincter disturbancesSphincter disturbances